Adolescent Care Survey

Welcome

Help us know if we're doing a good job providing health care to patients your age. Please share your thoughts on your most recent medical visit to the Corner Health Center.

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* 1. What is your age

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* 2. Gender

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* 3. Race/Ethnicity

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* 4. What type of visit was your most recent medical visit?

Physical or check-up "Well Visit"

Short visit about illness or injury "Sick Visit"

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* 5. At your most recent visit, did the provider (doctor or medical provider)...

	Definitely Yes	Mostly Yes	Mostly No	Definitely No
listen carefully to you?	listen carefully to you? Definitely Yes	listen carefully to you? Mostly Yes	listen carefully to you? Mostly No	listen carefully to you? Definitely No
talk to you (rather than your parent/guardian)?	talk to you (rather than your parent/guardian)? Definitely Yes	talk to you (rather than your parent/guardian)? Mostly Yes	talk to you (rather than your parent/guardian)? Mostly No	talk to you (rather than your parent/guardian)? Definitely No
ask about your physical and mental health?	ask about your physical and mental health? Definitely Yes	ask about your physical and mental health? Mostly Yes	ask about your physical and mental health? Mostly No	ask about your physical and mental health? Definitely No
talk privately with you (without your parent/guardian in the room)?	talk privately with you (without your parent/guardian in the room)? Definitely Yes	talk privately with you (without your parent/guardian in the room)? Mostly Yes	talk privately with you (without your parent/guardian in the room)? Mostly No	talk privately with you (without your parent/guardian in the room)? Definitely No
show respect for what you have to say?	show respect for what you have to say? Definitely Yes	show respect for what you have to say? Mostly Yes	show respect for what you have to say? Mostly No	show respect for what you have to say? Definitely No
explain things in a way that is understandable?	explain things in a way that is understandable? Definitely Yes	explain things in a way that is understandable? Mostly Yes	explain things in a way that is understandable? Mostly No	explain things in a way that is understandable? Definitely No
spend enough time with you?	spend enough time with you? Definitely Yes	spend enough time with you? Mostly Yes	spend enough time with you? Mostly No	spend enough time with you? Definitely No
address all of your health needs?	address all of your health needs? Definitely Yes	address all of your health needs? Mostly Yes	address all of your health needs? Mostly No	address all of your health needs? Definitely No
have you privately fill out a survey about your health behaviors?	have you privately fill out a survey about your health behaviors? Definitely Yes	have you privately fill out a survey about your health behaviors? Mostly Yes	have you privately fill out a survey about your health behaviors? Mostly No	have you privately fill out a survey about your health behaviors? Definitely No
treat you in a non-judgmental way?	treat you in a non-judgmental way? Definitely Yes	treat you in a non-judgmental way? Mostly Yes	treat you in a non-judgmental way? Mostly No	treat you in a non-judgmental way? Definitely No

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* 6. Please give your opinion about getting health care at the Corner Health Center

	Definitely Yes	Mostly Yes	Mostly No	Definitely No
At this clinic, I can get information to better understand issues affecting my health.	At this clinic, I can get information to better understand issues affecting my health. Definitely Yes	At this clinic, I can get information to better understand issues affecting my health. Mostly Yes	At this clinic, I can get information to better understand issues affecting my health. Mostly No	At this clinic, I can get information to better understand issues affecting my health. Definitely No
I will tell a provider my concerns, even if they don't ask.	I will tell a provider my concerns, even if they don't ask. Definitely Yes	I will tell a provider my concerns, even if they don't ask. Mostly Yes	I will tell a provider my concerns, even if they don't ask. Mostly No	I will tell a provider my concerns, even if they don't ask. Definitely No
I am completely honest when talking to my provider about my health, personal life, and activities.	I am completely honest when talking to my provider about my health, personal life, and activities. Definitely Yes	I am completely honest when talking to my provider about my health, personal life, and activities. Mostly Yes	I am completely honest when talking to my provider about my health, personal life, and activities. Mostly No	I am completely honest when talking to my provider about my health, personal life, and activities. Definitely No
I know what health services I can get without my parents knowing or saying it is OK ("confidential services").	I know what health services I can get without my parents knowing or saying it is OK ("confidential services"). Definitely Yes	I know what health services I can get without my parents knowing or saying it is OK ("confidential services"). Mostly Yes	I know what health services I can get without my parents knowing or saying it is OK ("confidential services"). Mostly No	I know what health services I can get without my parents knowing or saying it is OK ("confidential services"). Definitely No
I know how to contact my provider or the clinic if I have any questions or concerns.	I know how to contact my provider or the clinic if I have any questions or concerns. Definitely Yes	I know how to contact my provider or the clinic if I have any questions or concerns. Mostly Yes	I know how to contact my provider or the clinic if I have any questions or concerns. Mostly No	I know how to contact my provider or the clinic if I have any questions or concerns. Definitely No
The reception area and office staff are welcoming to teens and young adults.	The reception area and office staff are welcoming to teens and young adults. Definitely Yes	The reception area and office staff are welcoming to teens and young adults. Mostly Yes	The reception area and office staff are welcoming to teens and young adults. Mostly No	The reception area and office staff are welcoming to teens and young adults. Definitely No
I would recommend this clinic to other teens and young adults.	I would recommend this clinic to other teens and young adults. Definitely Yes	I would recommend this clinic to other teens and young adults. Mostly Yes	I would recommend this clinic to other teens and young adults. Mostly No	I would recommend this clinic to other teens and young adults. Definitely No

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* 7. Optional: Please provide us with your email address if you'd like to be entered to win the $150 e-gift card.

Email Address